Medical Transcription Physical Examination Normocephalic

Essential SIGNS: Blood weight 132/84, beat 92, breaths 17, temperature 98.5, beat oximetry 98% on room air.

GENERAL: The patient is conscious, ready and arranged x3, albeit lazy.

HEENT: Normocephalic, atraumatic. Extraocular muscles are in place. Students are equivalent, round, and receptive to light reciprocally. Mucous films are clammy.

NECK: Supple.

LUNGS: Clear to auscultation reciprocally. No wheezes, rhonchi or rales.

HEART: Regular rate and mood. No mumbles, rubs or dashes.

Guts: Active inside sounds are available. No bounce back, no guarding, no peritoneal signs.

Furthest points: Without clubbing, cyanosis or edema.

NEUROLOGIC: Cranial nerves II through XII are in place. Quality is 5/5. Walk is typical. Sensation is in place. No dysdiadochokinesia or dysmetria.

PHYSICAL EXAMINATION: GENERAL: The patient is very much grown, thin, in no clear misery. She is ready and arranged x3. Imperative SIGNS: Blood weight 142/52 mmHg, beat normal at 20 beats for every moment, breaths unlabored at 20 breaths for each moment, and temperature as of now afebrile. HEENT: Extraocular developments are in place. Conjunctivae pink. Mucous layers are clammy. NECK: There is no jugular venous enlargement. Carotid upstrokes appear to be typical reciprocally with a delicate bruit auscultated on the privilege. Trachea is midline. There is no thyromegaly. HEART: PMI is hard to appreciate. To begin with and second heart sounds are customary and of typical force. There is review 1/6 systolic mumble heard over the left sternal fringe. No rubs or jogs are available. LUNGS: Scant rales acknowledged at the bases reciprocally. Midriff: Soft, nontender, and nondistended with ordinary gut sounds. There is no hepatosplenomegaly. Pulsatile masses not acknowledged. Limits: Negative for cyanosis, clubbing or edema. Fringe heartbeats are +2 all through. NEUROLOGIC: Grossly in place. No central shortages.


Indispensable SIGNS: Temperature 98.6, breaths 16, beat 84, BP 114/78, O2 sat 100% on room air.

GENERAL: The patient is an all around grew, very much sustained female in no intense misery.

HEENT: Extraocular muscles are in place. Students are equivalent, round, responsive to light. ENT: Nares patent. Throat: No erythema. Mucous layers are clammy. TMs are silvery respectively.

NECK: Supple with no lymphadenopathy.

LUNGS: Clear to auscultation reciprocally except for a couple crackles in the correct base that unmistakable with hack.

HEART: Regular rate and beat without any mumbles, rubs or jogs.

MUSCULOSKELETAL: The patient moves all furthest points well and ambulates freely.

SKIN: Warm and dry without any rashes.

PSYCHIATRIC: The patient is charming and agreeable with a suitable state of mind and influence.

PHYSICAL EXAMINATION: VITAL SIGNS: Blood weight: 122/78. Beat: 81, normal. GENERAL: He is a very much sustained, all around created (XX)- year-old male whining of 7/10 trunk torment, who shows up intensely sick. HEENT: Eyes: No scleral icterus. No xanthelasma. Mouth: No oral whiteness or cyanosis. NECK: Carotid heartbeats are full and without bruit. Trunk: Clear to auscultation and percussion.

Heart EXAM: Cardiac drive feels ordinary. Heart sounds are far off. Mid-region: Soft, nontender. Furthest points: No edema, no varicose veins. Focal NERVOUS SYSTEM: Oriented x 3. SKIN: Cool and dry.

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